2025-02-01T08:42:33-06:00 2023-12-31 721396621 CARR RIGGS & INGRAM LLC 4267 LAFAYETTE STREET MARIANNA FL 32446 990 2023-01-01 863052869 JACKSON HOSPITAL QALICB INC JACK 8507182623 4250 HOSPITAL DRIVE MARIANNA FL 32446 KEITH WILLIAMS PRESIDENT 8505730231 2025-01-31 1 1 SARA HUGHES P00094714 8505263207 2025-01-31 2023 2025-03-06 01:10:19Z KEITH WILLIAMS 4250 HOSPITAL DRIVE MARIANNA FL 32446 124848 0 X N/A X 2021 FL TO REDUCE THE BURDENS OF GOVERNMENT BY SERVING AS A TYPE III SUPPORTING ORGANIZATION FOR THE BENEFIT OF AND TO SUPPORT THE JACKSON HOSPITAL BOARD OF TRUSTEES AND THE GOVERNING BODY OF THE JACKSON COUNTY HOSPITAL DISTRICT. 3 2 0 0 0 0 0 0 0 0 0 0 -1689577 -1871397 -1689577 -1871397 0 0 0 0 0 0 0 0 0 0 0 0 0 -1689577 -1871397 35455679 33547127 13549155 13512000 21906524 20035127 X TO REDUCE THE BURDENS OF GOVERNMENT BY SERVING AS A TYPE III SUPPORTING ORGANIZATION FOR THE BENEFIT OF AND TO SUPPORT THE JACKSON HOSPITAL BOARD OF TRUSTEES AND THE GOVERNING BODY OF THE JACKSON COUNTY HOSPITAL DISTRICT. 0 0 A. APPLICANT WAS FORMED UNDER THE FLORIDA NONPROFIT CORPORATION ACT TO SERVE AS A TYPE 3 FUNCTIONALLY INTEGRATED SUPPORTING ORGANIZATION WITHIN THE MEANING OF SECTION 509(A)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED (THE CODE), TREASURY REGULATIONS SECTION 1.509(A)-4(I), AND NOTICE 2014-4 THAT IS OPERATED IN CONNECTION WITH AND FOR THE BENEFIT OF THE JACKSON COUNTY HOSPITAL DISTRICT, A PUBLIC, NON-PROFIT INDEPENDENT SPECIAL DISTRICT ESTABLISHED UNDER CHAPTER 2003-363 OF THE LAWS OF FLORIDA (THE HOSPITAL DISTRICT). APPLICANT WAS FORMED TO REDUCE THE BURDENS OF GOVERNMENT BY SERVING AS A QUALIFIED ACTIVE LOW-INCOME COMMUNITY BUSINESS OR QALICB (AS DEFINED IN CODE SECTION 45D(D)(2)) TO FACILITATE THE FINANCING OF (I) CERTAIN REPAIRS TO THE JACKSON COUNTY HOSPITAL (THE HOSPITAL), WHICH SUFFERED SIGNIFICANT DAMAGE AS A RESULT OF HURRICANE MICHAEL IN 2018, (II) THE RELOCATION AND EXPANSION OF THE HOSPITAL'S NUCLEAR MEDICINE DEPARTMENT, AND (III) THE ACQUISITION OF MEDICAL EQUIPMENT FOR USE IN THE HOSPITAL (THE FOREGOING IS COLLECTIVELY REFERRED TO IN THIS APPLICATION AS THE PROJECT). IN CONNECTION WITH THE PROJECT, APPLICANT WILL LEASE THE HOSPITAL BUILDING AND THE REAL PROPERTY ON WHICH THE HOSPITAL IS LOCATED (THE PROJECT PROPERTY) PURSUANT TO A LONG-TERM GROUND LEASE WITH THE HOSPITAL DISTRICT. APPLICANT WILL THEN SUBLEASE THE COMPLETED PROJECT (INCLUDING THE NEWLY ACQUIRED EQUIPMENT) BACK TO THE HOSPITAL DISTRICT PURSUANT TO A SUBLEASE. THE HOSPITAL DISTRICT WILL CONTINUE TO OPERATE THE HOSPITAL. 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 3 2 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 0 0 0 FL X BROOKE DONALDSON 8507182623 4250 HOSPITAL DRIVE MARIANNA FL 32446 X KEITH WILLIAMS PRESIDENT 1.00 1.00 X X 0 0 0 JORGE GARCIA SECRETARY 0.00 X X 0 0 0 ROBERT REIFF TREASURER 0.00 X X 0 0 0 0 0 0 0 0 0 0 0 124848 1996245 -1871397 -1871397 -1871397 -1871397 -1871397 0 0 0 0 0 0 877155 741899 130468 100360 35950630 3973486 33693792 31977144 754264 727724 35455679 33547127 49155 12000 13500000 13500000 13549155 13512000 X 0 0 23596101 23596101 -1689577 -3560974 21906524 20035127 35455679 33547127 -1871397 0 X 0 0 0 X X X 1 JACKSON COUNTY HOSPITAL DISTRICT 596001321 6 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 X SECTION A PART IV SECTION E 1C THE ORGANIZATION WAS CREATED TO PROVIDE SUPPORT TO JACKSON COUNTY HOSPITAL DISTRICT, A GOVERNMENTAL ENTITY WITH THE FEIN 59-6001321. THE AGREEMENTS AND TRANSACTIONS ENGAGED IN BY THE ORGANIZATION ARE ALL UNDERTAKEN TO BENEFIT THE HOSPITAL. SCHEDULE A, PART IV SECTION D3 THE SUPPORTED GOVERNMENTAL ORGANIZATION (THE HOSPITAL) WAS INVOLVED IN CREATING AND MAINTAINING THE BOOKS FOR THE ENTITY FOR THE BENEFIT OF THE HOSPITAL. THERE ARE VERY FEW TRANSACTIONS AND THEY ARE ALL IN CONNECTION WITH THE AGREEMENTS BETWEEN THE ENTITIES TO BENEFIT THE HOSPITAL. 29115600 1850054 27265546 6835030 2123432 4711598 31977144 FORM 990, PART VI, SECTION B, LINE 11B A BOARD MEETING IS CALLED AND THE 990 IS REVIEWED WITH THE OFFICERS. FORM 990, PART VI, SECTION B, LINE 12C ANNUAL REVIEW BY HOSPITAL BOARD FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST JACKSON COUNTY HOSPITAL DISTRICT 4250 HOSPITAL DRIVE MARIANNA FL 32446 596001321 HOSPITAL FL 501(C)(3) LINE 3 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 JACKSON COUNTY HOSPITAL DISTRICT J 124848