SHG HEALTHCARE GROUP LTD HEALTH CARE BENEFITS TRUST: Form 990, tax year 2015
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- Organization
- SHG HEALTHCARE GROUP LTD HEALTH CARE BENEFITS TRUST (EIN 20-2464129)
- Tax period
- 2015-06-01 to 2016-05-31
- Filed
- 2017-01-12
- IRS object ID
- 201740129349300319
- Schema version
- 2015v3.0
- Source
- Download XML · Original 990 at ProPublica
Every field in the e-filed return. Faint text is the IRS element name, for citing.
Return header ReturnHeader
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return | 2017-01-12T11:13:44-06:00 | ReturnTs |
| Tax Period End | 2016-05-31 | TaxPeriodEndDt |
Preparer Firm PreparerFirmGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Firm EIN | 752409112 | PreparerFirmEIN |
Preparer Firm Name PreparerFirmName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | HUSELTON MORGAN & MAULTSBY PC | BusinessNameLine1Txt |
Preparer US Address PreparerUSAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 12221 MERIT DRIVE SUITE 1800 | AddressLine1Txt |
| City | DALLAS | CityNm |
| State Abbreviation | TX | StateAbbreviationCd |
| ZIP | 75251 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Return Type | 990 | ReturnTypeCd |
| Tax Period Begin | 2015-06-01 | TaxPeriodBeginDt |
Filer Filer
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 202464129 | EIN |
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FOURSQUARE HEALTHCARE LTD | BusinessNameLine1Txt |
| Business Name Line2 | BENEFITS TRUST | BusinessNameLine2Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Control | FOUR | BusinessNameControlTxt |
| Phone | 9723039000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4311 OAK LAWN AVE STE 400 | AddressLine1Txt |
| City | DALLAS | CityNm |
| State Abbreviation | TX | StateAbbreviationCd |
| ZIP | 75219 | ZIPCd |
Business Officer BusinessOfficerGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Person | SHANE LEWIS | PersonNm |
| Person Title | PRESIDENT | PersonTitleTxt |
| Phone | 9723039000 | PhoneNum |
| Signature | 2017-01-12 | SignatureDt |
| Discuss With Paid Preparer | Yes (1) | DiscussWithPaidPreparerInd |
Preparer Person PreparerPersonGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Preparer Person | CARMEL B WOOD | PreparerPersonNm |
| PTIN | P00443944 | PTIN |
| Phone | 9724041010 | PhoneNum |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Tax | 2015 | TaxYr |
| Build TS | 2021-01-29 14:40:06Z | BuildTS |
Form 990 IRS990
| Field | Value | IRS element (for citing) |
|---|---|---|
| Principal Officer | SHANE LEWIS | PrincipalOfficerNm |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4311 OAK LAWN AVE STE 400 | AddressLine1Txt |
| City | DALLAS | CityNm |
| State Abbreviation | TX | StateAbbreviationCd |
| ZIP | 75219 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Gross Receipts | $2,009,881 | GrossReceiptsAmt |
| Group Return For Affiliates | 0 | GroupReturnForAffiliatesInd |
| Organization501c | Yes (X) | Organization501cInd |
| Website Address | N/A | WebsiteAddressTxt |
| Type Of Organization Trust | Yes (X) | TypeOfOrganizationTrustInd |
| Formation | 2005 | FormationYr |
| Legal Domicile State | TX | LegalDomicileStateCd |
| Activity Or Mission | EMPLOYEE INSURANCE BENEFITS | ActivityOrMissionDesc |
| Voting Members Governing Body | 2 | VotingMembersGoverningBodyCnt |
| Voting Members Independent | 0 | VotingMembersIndependentCnt |
| Total Employee | 0 | TotalEmployeeCnt |
| Total Volunteers | 0 | TotalVolunteersCnt |
| Total Gross UBI | $0 | TotalGrossUBIAmt |
| Net Unrelated Bus Txbl Incm | $0 | NetUnrelatedBusTxblIncmAmt |
| PY Contributions Grants | $0 | PYContributionsGrantsAmt |
| CY Contributions Grants | $0 | CYContributionsGrantsAmt |
| PY Program Service Revenue | $1,711,530 | PYProgramServiceRevenueAmt |
| CY Program Service Revenue | $2,009,881 | CYProgramServiceRevenueAmt |
| PY Investment Income | $0 | PYInvestmentIncomeAmt |
| CY Investment Income | $0 | CYInvestmentIncomeAmt |
| PY Other Revenue | $0 | PYOtherRevenueAmt |
| CY Other Revenue | $0 | CYOtherRevenueAmt |
| PY Total Revenue | $1,711,530 | PYTotalRevenueAmt |
| CY Total Revenue | $2,009,881 | CYTotalRevenueAmt |
| PY Grants And Similar Paid | $0 | PYGrantsAndSimilarPaidAmt |
| CY Grants And Similar Paid | $0 | CYGrantsAndSimilarPaidAmt |
| PY Benefits Paid To Members | $1,042,530 | PYBenefitsPaidToMembersAmt |
| CY Benefits Paid To Members | $1,639,254 | CYBenefitsPaidToMembersAmt |
| PY Salaries Comp Emp Bnft Paid | $0 | PYSalariesCompEmpBnftPaidAmt |
| CY Salaries Comp Emp Bnft Paid | $0 | CYSalariesCompEmpBnftPaidAmt |
| PY Total Prof Fndrsng Expns | $0 | PYTotalProfFndrsngExpnsAmt |
| CY Total Prof Fndrsng Expns | $0 | CYTotalProfFndrsngExpnsAmt |
| CY Total Fundraising Expense | $0 | CYTotalFundraisingExpenseAmt |
| PY Other Expenses | $458,628 | PYOtherExpensesAmt |
| CY Other Expenses | $706,021 | CYOtherExpensesAmt |
| PY Total Expenses | $1,501,158 | PYTotalExpensesAmt |
| CY Total Expenses | $2,345,275 | CYTotalExpensesAmt |
| PY Revenues Less Expenses | $210,372 | PYRevenuesLessExpensesAmt |
| CY Revenues Less Expenses | -$335,394 | CYRevenuesLessExpensesAmt |
| Total Assets BOY | $1,095,227 | TotalAssetsBOYAmt |
| Total Assets EOY | $880,872 | TotalAssetsEOYAmt |
| Total Liabilities BOY | $105,860 | TotalLiabilitiesBOYAmt |
| Total Liabilities EOY | $226,899 | TotalLiabilitiesEOYAmt |
| Net Assets Or Fund Balances BOY | $989,367 | NetAssetsOrFundBalancesBOYAmt |
| Net Assets Or Fund Balances EOY | $653,973 | NetAssetsOrFundBalancesEOYAmt |
| Mission | TO PROVIDE HEALTH INSURANCE BENEFITS TO EMPLOYEES OF FOURSQUARE HEALTHCARE, LTD. AND AFFILIATED COMPANIES AND THEIR DEPENDENTS. | MissionDesc |
| Significant New Program Srvc | 0 | SignificantNewProgramSrvcInd |
| Significant Change | 0 | SignificantChangeInd |
| Expense | $2,345,275 | ExpenseAmt |
| Revenue | $2,009,881 | RevenueAmt |
| Desc | PROVIDED HEALTH INSURANCE BENEFITS, DENTAL INSURANCE BENEFITS AND VISION INSURANCE BENEFITS TO EMPLOYEES OF FOURSQUARE HEALTHCARE, LTD. AND AFFILIATED COMPANIES AND THEIR DEPENDENTS. | Desc |
| Total Program Service Expenses | $2,345,275 | TotalProgramServiceExpensesAmt |
| Described In Section501c3 | 0 | DescribedInSection501c3Ind |
| Schedule B Required | 0 | ScheduleBRequiredInd |
| Political Campaign Acty | 0 | PoliticalCampaignActyInd |
| Subject To Proxy Tax | 0 | SubjectToProxyTaxInd |
| Donor Advised Fund | 0 | DonorAdvisedFundInd |
| Conservation Easements | 0 | ConservationEasementsInd |
| Collections Of Art | 0 | CollectionsOfArtInd |
| Credit Counseling | 0 | CreditCounselingInd |
| Temp Or Permanent Endowments | 0 | TempOrPermanentEndowmentsInd |
| Report Land Building Equipment | 0 | ReportLandBuildingEquipmentInd |
| Report Investments Other Sec | 0 | ReportInvestmentsOtherSecInd |
| Report Program Related Invst | 0 | ReportProgramRelatedInvstInd |
| Report Other Assets | 0 | ReportOtherAssetsInd |
| Report Other Liabilities | Yes (1) | ReportOtherLiabilitiesInd |
| Include FIN48 Footnote | 0 | IncludeFIN48FootnoteInd |
| Independent Audit Fincl Stmt | Yes (1) | IndependentAuditFinclStmtInd |
| Consolidated Audit Fincl Stmt | 0 | ConsolidatedAuditFinclStmtInd |
| School Operating | 0 | SchoolOperatingInd |
| Foreign Office | 0 | ForeignOfficeInd |
| Foreign Activities | 0 | ForeignActivitiesInd |
| More Than5000 K To Org | 0 | MoreThan5000KToOrgInd |
| More Than5000 K To Individuals | 0 | MoreThan5000KToIndividualsInd |
| Professional Fundraising | 0 | ProfessionalFundraisingInd |
| Fundraising Activities | 0 | FundraisingActivitiesInd |
| Gaming Activities | 0 | GamingActivitiesInd |
| Operate Hospital | 0 | OperateHospitalInd |
| Grants To Organizations | 0 | GrantsToOrganizationsInd |
| Grants To Individuals | 0 | GrantsToIndividualsInd |
| Schedule J Required | Yes (1) | ScheduleJRequiredInd |
| Tax Exempt Bonds | 0 | TaxExemptBondsInd |
| Loan Outstanding | 0 | LoanOutstandingInd |
| Grant To Related Person | 0 | GrantToRelatedPersonInd |
| Business Rln With Org Mem | 0 | BusinessRlnWithOrgMemInd |
| Business Rln With Fam Mem | 0 | BusinessRlnWithFamMemInd |
| Business Rln With Officer Ent | 0 | BusinessRlnWithOfficerEntInd |
| Deductible Non Cash Contri | 0 | DeductibleNonCashContriInd |
| Deductible Art Contribution | 0 | DeductibleArtContributionInd |
| Terminate Operations | 0 | TerminateOperationsInd |
| Partial Liquidation | 0 | PartialLiquidationInd |
| Disregarded Entity | 0 | DisregardedEntityInd |
| Related Entity | Yes (1) | RelatedEntityInd |
| Related Organization Ctrl Ent | 0 | RelatedOrganizationCtrlEntInd |
| Activities Conducted Prtshp | 0 | ActivitiesConductedPrtshpInd |
| Schedule O Required | Yes (1) | ScheduleORequiredInd |
| IRP Document | 0 | IRPDocumentCnt |
| IRP Document W2 G | 0 | IRPDocumentW2GCnt |
| Employee | 0 | EmployeeCnt |
| Unrelated Bus Incm Over Limit | 0 | UnrelatedBusIncmOverLimitInd |
| Foreign Financial Account | 0 | ForeignFinancialAccountInd |
| Prohibited Tax Shelter Trans | 0 | ProhibitedTaxShelterTransInd |
| Taxable Party Notification | 0 | TaxablePartyNotificationInd |
| Nondeductible Contributions | 0 | NondeductibleContributionsInd |
| Quid Pro Quo Contributions | 0 | QuidProQuoContributionsInd |
| Form8282 Property Disposed Of | 0 | Form8282PropertyDisposedOfInd |
| Indoor Tanning Services | 0 | IndoorTanningServicesInd |
| Info In Schedule O Part VI | Yes (X) | InfoInScheduleOPartVIInd |
| Governing Body Voting Members | 2 | GoverningBodyVotingMembersCnt |
| Independent Voting Member | 0 | IndependentVotingMemberCnt |
| Family Or Business Rln | Yes (1) | FamilyOrBusinessRlnInd |
| Delegation Of Mgmt Duties | 0 | DelegationOfMgmtDutiesInd |
| Change To Org Documents | 0 | ChangeToOrgDocumentsInd |
| Material Diversion Or Misuse | 0 | MaterialDiversionOrMisuseInd |
| Members Or Stockholders | 0 | MembersOrStockholdersInd |
| Election Of Board Members | 0 | ElectionOfBoardMembersInd |
| Decisions Subject To Approva | 0 | DecisionsSubjectToApprovaInd |
| Minutes Of Governing Body | 0 | MinutesOfGoverningBodyInd |
| Minutes Of Committees | 0 | MinutesOfCommitteesInd |
| Officer Mailing Address | 0 | OfficerMailingAddressInd |
| Local Chapters | 0 | LocalChaptersInd |
| Form990 Provided To Gvrn Body | Yes (1) | Form990ProvidedToGvrnBodyInd |
| Conflict Of Interest Policy | 0 | ConflictOfInterestPolicyInd |
| Whistleblower Policy | 0 | WhistleblowerPolicyInd |
| Document Retention Policy | Yes (1) | DocumentRetentionPolicyInd |
| Compensation Process CEO | 0 | CompensationProcessCEOInd |
| Compensation Process Other | 0 | CompensationProcessOtherInd |
| Investment In Joint Venture | 0 | InvestmentInJointVentureInd |
| Upon Request | Yes (X) | UponRequestInd |
Books In Care Of Detail BooksInCareOfDetail
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FOURSQUARE HEALTHCARE LTD | BusinessNameLine1Txt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Phone | 9723039000 | PhoneNum |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4311 OAK LAWN AVE STE 400 | AddressLine1Txt |
| City | DALLAS | CityNm |
| State Abbreviation | TX | StateAbbreviationCd |
| ZIP | 75219 | ZIPCd |
Form990 Part VII Section A Form990PartVIISectionAGrp (2 entries)
| TitleTitleTxt | Average Hours Per WeekAverageHoursPerWeekRt | Average Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRt | Individual Trustee Or DirectorIndividualTrusteeOrDirectorInd | Reportable Comp From OrgReportableCompFromOrgAmt | Reportable Comp From Rltd OrgReportableCompFromRltdOrgAmt | Other CompensationOtherCompensationAmt |
|---|---|---|---|---|---|---|
| SHANE LEWIS | ||||||
| VP/CFO | 1.00 | 39.00 | Yes (X) | $0 | $164,972 | $8,733 |
| DON MILLER | ||||||
| PRESIDENT | 1.00 | 39.00 | Yes (X) | $0 | $154,810 | $11,463 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Reportable Comp From Org | $0 | TotalReportableCompFromOrgAmt |
| Tot Reportable Comp Rltd Org | $319,782 | TotReportableCompRltdOrgAmt |
| Total Other Compensation | $20,196 | TotalOtherCompensationAmt |
| Indiv Rcvd Greater Than100 K | 0 | IndivRcvdGreaterThan100KCnt |
| Former Ofcr Employees Listed | 0 | FormerOfcrEmployeesListedInd |
| Total Comp Greater Than150 K | Yes (1) | TotalCompGreaterThan150KInd |
| Compensation From Other Srcs | 0 | CompensationFromOtherSrcsInd |
Contractor Compensation ContractorCompensationGrp
Contractor Name ContractorName
Business Name BusinessName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | CIGNA HEALTH AND LIFE INSURANCE COMPANY | BusinessNameLine1Txt |
Contractor Address ContractorAddress
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 900 COTTAGE GROVE ROAD | AddressLine1Txt |
| City | HARTFORD | CityNm |
| State Abbreviation | CT | StateAbbreviationCd |
| ZIP | 06152 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Services | TPA FEES | ServicesDesc |
| Compensation | $230,549 | CompensationAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Cntrct Rcvd Greater Than100 K | 1 | CntrctRcvdGreaterThan100KCnt |
Program Service Revenue ProgramServiceRevenueGrp (2 entries)
| DescDesc | BusinessBusinessCd | Total Revenue ColumnTotalRevenueColumnAmt | Related Or Exempt Func IncomeRelatedOrExemptFuncIncomeAmt |
|---|---|---|---|
| EMPLOYEE CONTRIBUTION | 525100 | $1,013,924 | $1,013,924 |
| EMPLOYER CONTRIBUTIONS | 525100 | $995,957 | $995,957 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Program Service Revenue | $2,009,881 | TotalProgramServiceRevenueAmt |
Total Revenue TotalRevenueGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Revenue Column | $2,009,881 | TotalRevenueColumnAmt |
| Related Or Exempt Func Income | $2,009,881 | RelatedOrExemptFuncIncomeAmt |
| Unrelated Business Revenue | $0 | UnrelatedBusinessRevenueAmt |
| Exclusion | $0 | ExclusionAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Info In Schedule O Part IX | Yes (X) | InfoInScheduleOPartIXInd |
Benefits To Members BenefitsToMembersGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $1,639,254 | TotalAmt |
| Program Services | $1,639,254 | ProgramServicesAmt |
Fees For Services Management FeesForServicesManagementGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $306,004 | TotalAmt |
| Program Services | $306,004 | ProgramServicesAmt |
Fees For Services Accounting FeesForServicesAccountingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,300 | TotalAmt |
| Program Services | $15,300 | ProgramServicesAmt |
Fees For Services Other FeesForServicesOtherGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $15,810 | TotalAmt |
| Program Services | $15,810 | ProgramServicesAmt |
Insurance InsuranceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $368,907 | TotalAmt |
| Program Services | $368,907 | ProgramServicesAmt |
Total Functional Expenses TotalFunctionalExpensesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total | $2,345,275 | TotalAmt |
| Program Services | $2,345,275 | ProgramServicesAmt |
| Management And General | $0 | ManagementAndGeneralAmt |
| Fundraising | $0 | FundraisingAmt |
Cash Non Interest Bearing CashNonInterestBearingGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $196,636 | BOYAmt |
| EOY | $111,546 | EOYAmt |
Accounts Receivable AccountsReceivableGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $898,591 | BOYAmt |
| EOY | $769,326 | EOYAmt |
Total Assets TotalAssetsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,095,227 | BOYAmt |
| EOY | $880,872 | EOYAmt |
Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $98,449 | BOYAmt |
| EOY | $207,255 | EOYAmt |
Other Liabilities OtherLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $7,411 | BOYAmt |
| EOY | $19,644 | EOYAmt |
Total Liabilities TotalLiabilitiesGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $105,860 | BOYAmt |
| EOY | $226,899 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Org Does Not Follow SFAS117 | Yes (X) | OrgDoesNotFollowSFAS117Ind |
Cap Stk Tr Prin Current Funds CapStkTrPrinCurrentFundsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Pd In Cap Srpls Land Bldg Eqp Fund PdInCapSrplsLandBldgEqpFundGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $0 | BOYAmt |
| EOY | $0 | EOYAmt |
Rtn Earn Endowment Incm Oth Fnds RtnEarnEndowmentIncmOthFndsGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $989,367 | BOYAmt |
| EOY | $653,973 | EOYAmt |
Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $989,367 | BOYAmt |
| EOY | $653,973 | EOYAmt |
Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| BOY | $1,095,227 | BOYAmt |
| EOY | $880,872 | EOYAmt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Reconcilation Revenue Expnss | -$335,394 | ReconcilationRevenueExpnssAmt |
| Other Changes In Net Assets | $0 | OtherChangesInNetAssetsAmt |
| Info In Schedule O Part XII | Yes (X) | InfoInScheduleOPartXIIInd |
| Method Of Accounting Accrual | Yes (X) | MethodOfAccountingAccrualInd |
| Accountant Compile Or Review | 0 | AccountantCompileOrReviewInd |
| FS Audited | Yes (1) | FSAuditedInd |
FS Audited Basis FSAuditedBasisGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Separate Basis Fincl Stmt | Yes (X) | SeparateBasisFinclStmtInd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Audit Committee | 0 | AuditCommitteeInd |
| Federal Grant Audit Required | 0 | FederalGrantAuditRequiredInd |
Schedule D IRS990ScheduleD
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Book Value Land Buildings | $0 | TotalBookValueLandBuildingsAmt |
Other Liabilities Org OtherLiabilitiesOrgGrp
| Field | Value | IRS element (for citing) |
|---|---|---|
| Desc | ACCRUED ADMINISTRATIVE FEES | Desc |
| Amt | $19,644 | Amt |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Total Liability | $19,644 | TotalLiabilityAmt |
| Total Rev Etc Audited Fincl Stmt | $2,009,881 | TotalRevEtcAuditedFinclStmtAmt |
| Revenue Not Reported | $0 | RevenueNotReportedAmt |
| Revenue Subtotal | $2,009,881 | RevenueSubtotalAmt |
| Revenue Not Reported Fincl Stmt | $0 | RevenueNotReportedFinclStmtAmt |
| Total Revenue Per Form990 | $2,009,881 | TotalRevenuePerForm990Amt |
| Tot Expns Etc Audited Fincl Stmt | $2,345,275 | TotExpnsEtcAuditedFinclStmtAmt |
| Expenses Not Reported | $0 | ExpensesNotReportedAmt |
| Expenses Subtotal | $2,345,275 | ExpensesSubtotalAmt |
| Expenses Not Rpt Fincl Stmt | $0 | ExpensesNotRptFinclStmtAmt |
| Total Expenses Per Form990 | $2,345,275 | TotalExpensesPerForm990Amt |
Schedule J IRS990ScheduleJ
| Field | Value | IRS element (for citing) |
|---|---|---|
| Severance Payment | 0 | SeverancePaymentInd |
| Supplemental Nonqual Rtr Plan | 0 | SupplementalNonqualRtrPlanInd |
| Equity Based Comp Arrngm | 0 | EquityBasedCompArrngmInd |
Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp (2 entries)
| TitleTitleTxt | Base Compensation Filing OrgBaseCompensationFilingOrgAmt | Compensation Based On Rltd OrgsCompensationBasedOnRltdOrgsAmt | Bonus Filing OrganizationBonusFilingOrganizationAmount | Bonus Related OrganizationsBonusRelatedOrganizationsAmt | Other Compensation Filing OrgOtherCompensationFilingOrgAmt | Other Compensation Rltd OrgsOtherCompensationRltdOrgsAmt | Deferred Compensation Flng OrgDeferredCompensationFlngOrgAmt | Deferred Comp Rltd OrgsDeferredCompRltdOrgsAmt | Nontaxable Benefits Filing OrgNontaxableBenefitsFilingOrgAmt | Nontaxable Benefits Rltd OrgsNontaxableBenefitsRltdOrgsAmt | Total Compensation Filing OrgTotalCompensationFilingOrgAmt | Total Compensation Rltd OrgsTotalCompensationRltdOrgsAmt | Comp Report Prior990 Filing OrgCompReportPrior990FilingOrgAmt | Comp Report Prior990 Rltd OrgsCompReportPrior990RltdOrgsAmt |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| SHANE LEWIS | ||||||||||||||
| VP/CFO | $0 | $164,972 | $0 | $0 | $0 | $0 | $0 | $8,733 | $0 | $0 | $0 | $173,705 | $0 | $0 |
| DON MILLER | ||||||||||||||
| PRESIDENT | $0 | $154,810 | $0 | $0 | $0 | $0 | $0 | $11,463 | $0 | $0 | $0 | $166,273 | $0 | $0 |
Schedule O IRS990ScheduleO
Supplemental Information Detail SupplementalInformationDetail (7 entries)
| Form And Line ReferenceFormAndLineReferenceDesc | ExplanationExplanationTxt |
|---|---|
| FORM 990, PART VI, SECTION A, LINE 2 | A TRUSTEE HAS A BUSINESS RELATIONSHIP WITH ANOTHER TRUSTEE. |
| FORM 990, PART VI, SECTION A, LINE 8A | THE ORGANIZATION HAS NOT HISTORICALLY DOCUMENTED MEETINGS OR WRITTEN ACTIONS TAKEN BY THE GOVERNING BODY. |
| FORM 990, PART VI, SECTION A, LINE 8B | THE ORGANIZATION HAS NOT HISTORICALLY DOCUMENTED MEETINGS OR WRITTEN ACTIONS TAKEN BY EACH COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. |
| FORM 990, PART VI, SECTION B, LINE 11 | AN ELECTRONIC COPY OF THE FORM 990 WAS SENT TO THE BOARD MEMBERS FOR REVIEW PRIOR TO FILING |
| FORM 990, PART VI, SECTION C, LINE 19 | AVAILABLE UPON REQUEST |
| FORM 990, PART IX, LINE 11G | OTHER FEES: PROGRAM SERVICE EXPENSES 15,810. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 15,810. |
| FORM 990, PART XII, LINE 2C: | THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. |
Schedule R IRS990ScheduleR
Id Related Org Txbl Partnership IdRelatedOrgTxblPartnershipGrp
Related Organization Name RelatedOrganizationName
| Field | Value | IRS element (for citing) |
|---|---|---|
| Business Name Line1 | FOURSQUARE HEALTHCARE LTD | BusinessNameLine1Txt |
US Address USAddress
| Field | Value | IRS element (for citing) |
|---|---|---|
| Address Line1 | 4311 OAK LAWN AVE STE 400 | AddressLine1Txt |
| City | DALLAS | CityNm |
| State Abbreviation | TX | StateAbbreviationCd |
| ZIP | 75219 | ZIPCd |
| Field | Value | IRS element (for citing) |
|---|---|---|
| EIN | 264219383 | EIN |
| Primary Activities | MANAGEMENT SERVICE | PrimaryActivitiesTxt |
| Legal Domicile State | TX | LegalDomicileStateCd |
| Direct Controlling NA | N/A | DirectControllingNACd |
| Predominant Income Type | N/A | PredominantIncomeTypeTxt |
| Disproportionate Allocations | 0 | DisproportionateAllocationsInd |
| General Or Managing Partner | 0 | GeneralOrManagingPartnerInd |
Id Related Org Txbl Corp Tr IdRelatedOrgTxblCorpTrGrp (5 entries)
| Address Line1USAddress/AddressLine1Txt | CityUSAddress/CityNm | State AbbreviationUSAddress/StateAbbreviationCd | ZIPUSAddress/ZIPCd | EINEIN | Primary ActivitiesPrimaryActivitiesTxt | Legal Domicile StateLegalDomicileStateCd | Direct Controlling NADirectControllingNACd | Entity TypeEntityTypeTxt | Controlled OrganizationControlledOrganizationInd |
|---|---|---|---|---|---|---|---|---|---|
| SENIOR CARE RESOURCES INC | |||||||||
| 4311 OAK LAWN AVE STE 400 | DALLAS | TX | 75219 | 208677258 | MANAGEMENT SERVICE | TX | N/A | S | 0 |
| SCC PARTNERS INC | |||||||||
| 4311 OAK LAWN AVE STE 400 | DALLAS | TX | 75219 | 270328553 | MANAGEMENT SERVICE | TX | N/A | S | 0 |
| NTF REALTY INC | |||||||||
| 4311 OAK LAWN AVE STE 400 | DALLAS | TX | 75219 | 752551115 | REAL ESTATE/RENTAL | TX | N/A | S | 0 |
| SHG ODESSA INC | |||||||||
| 4311 OAK LAWN AVE STE 400 | DALLAS | TX | 75219 | 454902945 | MANAGEMENT SERVICE | TX | N/A | S | 0 |
| FOURSQUARE SNF INC | |||||||||
| 4311 OAK LAWN AVE STE 400 | DALLAS | TX | 75219 | 465558477 | MANAGEMENT SERVICE | TX | N/A | S | 0 |
| Field | Value | IRS element (for citing) |
|---|---|---|
| Receipt Of Int Annts Rnts Rylts | 0 | ReceiptOfIntAnntsRntsRyltsInd |
| Gift Grnt Or Cap Contri To Oth Org | 0 | GiftGrntOrCapContriToOthOrgInd |
| Gift Grnt Cap Contri From Oth Org | 0 | GiftGrntCapContriFromOthOrgInd |
| Loans Or Guarantees To Other Org | 0 | LoansOrGuaranteesToOtherOrgInd |
| Loans Or Guarantees From Oth Org | 0 | LoansOrGuaranteesFromOthOrgInd |
| Div Related Organization | 0 | DivRelatedOrganizationInd |
| Asset Sale To Other Org | 0 | AssetSaleToOtherOrgInd |
| Asset Purchase From Other Org | 0 | AssetPurchaseFromOtherOrgInd |
| Asset Exchange | 0 | AssetExchangeInd |
| Rental Of Facilities To Oth Org | 0 | RentalOfFacilitiesToOthOrgInd |
| Rental Of Fclts From Oth Org | 0 | RentalOfFcltsFromOthOrgInd |
| Perform Of Services For Oth Org | 0 | PerformOfServicesForOthOrgInd |
| Perform Of Services By Other Org | 0 | PerformOfServicesByOtherOrgInd |
| Sharing Of Facilities | Yes (1) | SharingOfFacilitiesInd |
| Paid Employees Sharing | Yes (1) | PaidEmployeesSharingInd |
| Reimbursement Paid To Other Org | 0 | ReimbursementPaidToOtherOrgInd |
| Reimbursement Paid By Other Org | 0 | ReimbursementPaidByOtherOrgInd |
| Transfer To Other Org | 0 | TransferToOtherOrgInd |
| Transfer From Other Org | Yes (1) | TransferFromOtherOrgInd |
Transactions Related Org TransactionsRelatedOrgGrp (6 entries)
| Transaction TypeTransactionTypeTxt | InvolvedInvolvedAmt | Method Of Amount DeterminationMethodOfAmountDeterminationTxt |
|---|---|---|
| FOURSQUARE HEALTHCARE LTD | ||
| S | $254,240 | GENERAL LEDGER |
| SENIOR CARE RESOURCES INC | ||
| S | $671,422 | GENERAL LEDGER |
| NTF REALTY INC | ||
| S | $32,479 | GENERAL LEDGER |
| SCC PARTNERS INC | ||
| S | $636,204 | GENERAL LEDGER |
| SHG ODESSA INC | ||
| S | $180,424 | GENERAL LEDGER |
| FOURSQUARE SNF INC | ||
| S | $233,375 | GENERAL LEDGER |
Reasonable Cause Explanation ReasonableCauseExplanation
| Field | Value | IRS element (for citing) |
|---|---|---|
| Explanation | THE ENTITY WAS DELAYED FROM FILING BY THE ORIGINAL DUE DATE OF OCTOBER 15, 2016 DUE TO A FINANCIAL STATEMENT AUDIT IN PROCESS. THE EXTENSION FOR THE FORM 990 WAS INADVERTANTLY MISSED. THE RETURN WAS PREPARED AND FILED IMMEDIATELY UPON DISCOVERING THIS ERROR. THE DELAY IN FILING THIS RETURN DID NOT DELAY THE PAYMENT OF ANY FORM OF TAX AND THE ENTITY TAX SERIOUSLY THE OBLIGATION TO TIMELY FILE ALL REQURIED FILINGS. THE TAXPAYER REQUESTS ABATEMENT OF THE PENALTY FOR REASONABLE CAUSE. | ExplanationTxt |