official form 207 · in re bremerton health, llc case no. 19-43788 none list the legal actions,...

Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy

Bremerton Health, LLC

19-43788Case number (if known):

Debtor Name

Official Form 207

The debtor must answer every question. If more space is needed, attach a separate sheet to this form. On the top of any additional pages, write the debtor's name and case number (if known).

04/19

United States Bankruptcy Court for the Western District of Washington

Check if this is an amended filing

Part 1: Income

None

1. Gross Revenue from business

Identify the beginning and ending dates of the debtor's fiscal year, which may be a calendar year

Sources of Revenue Gross Revenue

(before deductions and exclusions)

Fiscal Year 12/1/2017 12/31/2017

Other

Operating a business $688,801.731.1 From To

Fiscal Year 1/1/2018 12/31/2018

Other

Operating a business $9,632,228.191.2 From To

Fiscal Year 1/1/2019 11/22/2019

Other

Operating a business $9,093,836.691.3 From To

None

Include revenue regardless of whether that revenue is taxable. Non-business income may include interest, dividends, money collected from lawsuits, and royalties. List each source and the gross revenue for each separately. Do not include revenue listed in line 1.

X

2. Non-business revenue

Description of sources of revenue

Gross Revenue from each source(before deductions and exclusions)

Part 2: List Certain Transfers Made Before Filing for Bankruptcy

Official Form 207 Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy

Case 19-43788-MJH Doc 11 Filed 01/07/20 Ent. 01/07/20 02:34:14 Pg. 1 of 22

In re Case No.Bremerton Health, LLC 19-43788

None

List payments of transfers - including expense reimbursements to any creditor, other than regular employee compensation, within 90 days before filing this case unless the aggregate value of all property transferred to that creditor is less than $6,825. (This amount may be adjusted on 4/01/22 and every 3 years after that with respect to cases filed on or after the date of adjustment.)

Creditor's name and address Dates Total amount or value Reasons for payment or transfer

3. Certain payments or transfers to creditors within 90 days before filing this case

Check all that applySee Exhibit Secured Debt

Unsecured Loan Payments

Suppliers or vendors

Services

Other

None

List payments or transfers, including expense reimbursements, made within 1 year before filing this case on debts owed to an insider or guaranteed or cosigned by an insider unless the aggregate value of all property transferred to or for the benefit of the insider is less than $6,825. (This amount may be adjusted on 4/01/22 and every 3 years after that with respect to cases filed on or after the date of adjustment.) Do not include any payments listed in line 3. Insiders include officers, directors, and anyone in control of a corporate debtor and their relatives; general partners of a partnership debtor and their relatives; affiliates of the debtor and insiders of such affiliates; and any managing agent of the debtor. 11 U.S.C. § 101(31).

Insider's name and address Dates Total amount or value Reasons for payment or transfer

4. Payments or other transfers of property made within 1 year before filing this case that benefited any insider

See Exhibit

Relationship to debtor

None

List all property of the debtor that was obtained by a creditor within 1 year before filing this case, including property repossessed by a creditor, sold at a foreclosure sale, transferred by a deed in lieu of foreclosure, or returned to the seller. Do not include property listed in line 6.

X

Creditor's name and address Description of the property Date

5. Repossessions, foreclosures, and returns

Value of property

None

List any creditor, including a bank or financial institution, that within 90 days before filing this case set off or otherwise took anything from an account of the debtor without permission or refused to make a payment at the debtor’s direction from an account of the debtor because the debtor owed a debt.

X

6. Setoffs

AmountDate action was taken

Creditor's name and address Description of the action creditor took

Part 3: Legal Actions or Assignments




None

List the legal actions, proceedings, investigations, arbitrations, mediations, and audits by federal or state agencies in which the debtor was involved in any capacity—within 1 year before filing this case.

7. Legal actions, administrative proceedings, court actions, executions, attachments, or governmental audits

Status of caseCourt or agency's name and addressCase title Nature of case

Pending

On appeal

Concluded

Lucretia Robertson; Estate of Sonia Darcheville; Esther Douglas; Anselmo Darcheville; Merlin Meulens; Edmond Meulens; Sonja Meulens v. Bremerton Health LLC dba Bremerton Health and Rehabilitation Center

Kitsap County Superior Court613 Division StreetPort Orchard, WA 98366

7.1 Medical malpractice suit

19-2-02184-18

Case number

Status of caseCourt or agency's name and addressCase title Nature of case

Pending

On appeal

Concluded

Medilogix, a Deleware limited liability company v. Apex Healthcare Partners LLC, a New York limited liability company; Cornerstone Healthcare Services LLC, a Washington limited liability company; North Auburn Health LLC, a Washington limited liability company; Bremerton Health LLC, a Washington limited liability company; Forest Ridge Health-Bremerton LLC, a Washington limited liability company; Riverside Nursing-Centralia LLC, a Washington limited liability company; Aldercrest Health-Edmonds LLC, a Washington limited liability company; Puget Sound Healthcare-Olympia LLC, a Washington limited liability company; Crestwood Convalescent-Port Angeles LLC, a Washington limited liability company; Fir Lane Health-Shelton LLC, a Washington limited liability company; Cherrywood Place-Spokane LLC, a Washington limited liability company; Franklin Hills Health-Spokane LLC, a Washington limited liability company; Gardens on University-Spokane Valley LLC, a Washington limited liability company; Care Center East Health-Portland LLC, an Oregon limited liability company; Meadow Park Health-St. Helen LLC, an Oregon limited liability company; Ivy Court-Coeur D'Alene LLC, an Idaho limited liability company; LaCross Health-Coeur D'Alene LLC, an Idaho limited liability company

Denver County District Court 520 West Colfax Avenue

Denver, CO 80204

7.2 Alleged failure to pay for rental cost of certain durable medical equipment and the alleged wrongful retention of that equipment

19cv31408

Case number




None

List any property in the hands of an assignee for the benefit of creditors during the 120 days before filing this case and any property in the hands of a receiver, custodian, or other court-appointed officer within 1 year before filing this case.

X

8. Assignments and receivership

ValueCustodian's name and address Description of the property

Part 4: Certain Gifts and Charitable Contributions

NoneX

9. List all gifts or charitable contributions the debtor gave to a recipient within 2 years before filing this case unless the aggregate value of gifts to that recipient is less than $1,000

ValueDates givenRecipient's name and address Description of the gifts or contributions

Part 5: Certain Losses

NoneX

10. All losses from fire, theft, or other casualty within 1 year before filing this case.

Value of property lostDate of lossDescription of the property lost and how the loss occurred

Amount of payments received for the loss

If you have received payments to cover the loss, for example, from insurance, government compensation, or tort liability, list the total received.List unpaid claims on Official Form 106 A/B (Schedule A/B: Assets - Real and Personal Property).

Part 6: Certain Payments of Transfers




None

List any payments of money or other transfers of property made by the debtor or person acting on behalf of the debtor within 1 year before the filing of this case to another person or entity, including attorneys, that the debtor consulted about debt consolidation or restructuring, seeking bankruptcy relief, or filing a bankruptcy case.

11. Payments related to bankruptcy

Total amount or valueDatesWho was paid or who received the transfer? Address

If not money, describe any property transferred

Foley Larder LLP IOLTA Trust Account 11/21/1911.1 $16,666.67

Email or website address

Who made the payment, if not debtor?



Foley & Lardner LLP 11/22/1911.2 $1717.00



Cornerstone Healthcare Services



Getzler Henrich & Associates LLC 11/05/1911.3 $50,000.00






Getzler Henrich & Associates LLC 11/21/1911.4 $120,000.00






Omni Agent Solutions 11/21/1911.5 $25,000.00






Paladin Management Group, LLC 11/22/1911.6 $7,000.00




THE PAYMENTS MADE TO GETZLER HENRICH & ASSOCIATES LLC; OMNI AGENT SOLUTIONS; AND PALADIN MANAGEMENT GROUP, LLC WERE PAID DIRECTLY TO THESE PROFESSIONALS BY CORNERSTONE HEALTHCARE SERVICES FOR THE BENEFIT OF EACH AND ALL OF THE DEBTORS. AS THE PAYMENTS WERE MADE IN GROSS TO THESE PARTIES, THE GROSS AMOUNT OF THE PAYMENT MADE TO THESE PROFESSIONALS ARE LISTED AS PAYMENTS ON EACH OF THE DEBTOR’S STATEMENT OF FINANCIAL AFFAIRS QUESTION 11.




None

List any payments or transfers of property made by the debtor or a person acting on behalf of the debtor within 10 years before the filing of this case to a self-settled trust or similar device.Do not include transfers already listed on this statement.

X

12. Self-settled trusts of which the debtor is a beneficiary

Total amount or valueDates transfers were made

Name of trust or device Describe any property transferred

None

List any transfers of money or other property - by sale, trade, or any other means - made by the debtor or a person acting on behalf of the debtor within 2 years before the filing of this case to another person, other than property transferred in the ordinary course of business or financial affairs.Include both outright transfers and transfers made as security. Do not include gifts or transfers previously listed on this statement.

X

13. Transfers not already listed on this statement

Total amount or valueDate transfer was made

Who received transfer? Address. Description of property transferred or payments received or debts paid in exchange.

Part 7: Previous Locations

Does not apply

List all previous addresses used by the debtor within 3 years before filing this case and the dates the addresses were used.

X

Address Dates of occupancy

14. Previous addresses

Part 8: Health Care Bankruptcies




Is the debtor primarily engaged in offering services and facilities for:- diagnosing or treating injury, deformity, or disease, or- providing any surgical, psychiatric, drug treatment, or obstetric care?

15. Health Care bankruptcies

No

Yes. Fill in the information below.

Go to Part 9.

If debtor provides meals and housing, number of patients in debtor's care

Facility name and address Nature of the business operation, including type of services the debtor provides

15.1 2701 Claire Ave Bremerton, WA 98310

97Nursing Home

Location where patient records are maintained How are records kept?

Westcom Point Click Care Electronically

Paper

Part 9: Personally Identifiable Information

16. Does the debtor collect and retain personally identifiable information of customers?

No

Yes. State the nature of the information collected and retained. Patient Records

Does the debtor have a privacy policy about that information?

No

Yes.

17. Within 6 years before filing this case, have any employees of the debtor been participants in any ERISA, 401(k), 403(b), or other pension or profit-sharing plan made available by the debtor as an employee benefit?

No

Yes. Does the debtor serve as plan administrator?

Go to Part 10.

No. Go to Part 10.

Yes. Fill in below:

Name of plan Employer identification number of plan

Has the plan been terminated?

No

Yes

EIN:

Part 10: Certain Financial Accounts, Safe Deposit Boxes, and Storage Units




None

Within 1 year before filing this case, were any financial accounts or instruments held in the debtor’s name, or for the debtor’s benefit, closed, sold, moved, or transferred?Include checking, savings, money market, or other financial accounts; certificates of deposit; and shares in banks, credit unions, brokerage houses, cooperatives, associations, and other financial institutions.

X

18. Closed financial accounts

Financial institution name and address

Last balance before closing or transfer

Type of account Date account was closed, sold, moved, or transferred

Last 4 digits of account number

Checking

Savings

Money Market

Brokerage

Other

None

List any safe deposit box or other depository for securities, cash, or other valuables the debtor now has or did have within 1 year before filing this case.

X

19. Safe deposit boxes

Does debtor still have it?

Description of contentsDepository institution name and address

Names of anyone with access to it. Address

No

Yes

None

List any property kept in storage units or warehouses within 1 year before filing this case. Do not include facilities that are in a part of a building in which the debtor does business.

X

20. Off-premises storage

Does debtor still have it?

Description of contentsFacility name and address Names of anyone with access to it. Address

No

Yes

Part 11: Property the Debtor Holds or Controls That the Debtor Does Not Own




None

List any property that the debtor holds or controls that another entity owns. Include any property borrowed from, being stored for, or held in trust. Do not list leased or rented property.

21. Property held for another

ValueDescription of the propertyOwner's name and address Location of the property

Facility Residents Resident Personal Fund Trust Account21.1 2701 Claire Ave Bremerton WA 98310 $15,409

Part 12: Details About Environmental Information

For the purpose of Part 12, the following definitions apply: - Environmental law means any statute or governmental regulation that concerns pollution, contamination, or hazardous material, regardless of the medium affected (air, land, water, or any other medium) - Site means any location, facility, or property, including disposal sites, that the debtor now owns, operates, or utilizes or that the debtor formerly owned, operated, or utilized. - Hazardous material means anything that an environmental law defines as hazardous or toxic, or describes as a pollutant, contaminant, or a similarly harmful substance.

22. Has the debtor been a party in any judicial or administrative proceeding under any environmental law? Include settlements and orders.

No

Yes. Provide details below.

Status of caseNature of the caseCase title Court or agency name and address

Pending

On appeal

ConcludedCase number

23. Has any governmental unit otherwise notified the debtor that the debtor may be liable or potentially liable under or in violation of an environmental law?

No


Date of noticeEnvironmental law, if knownSite name and address Governmental unit name and address




24. Has the debtor notified any governmental unit of any release of hazardous material?

No


Date of noticeEnvironmental law, if knownSite name and address Governmental unit name and address

Part 13: Details About the Debtor's Business or Connections to Any Business

None

List any business for which the debtor was an owner, partner, member, or otherwise a person in control within 6 years before filing this case.Include this information even if already listed in the Schedules.

X

Business name and address Describe the nature of the business

Employer identification number. Dates business existed

25. Other businesses in which the debtor has or has had an interest

None

Name and address Dates of service

26. Books, records, and financial statements26a. List all accountants and bookkeepers who maintained the debtor’s books and records within 2 years before filing this case.

Apex Global Solutions, LLC 400 Rella Blvd Suite 200 Montobello, NY 10901

12/1/17 - Current26a.1

None

Name and address Dates of service

26b. List all firms or individuals who have audited, compiled, or reviewed debtor’s books of account and records or prepared a financial statement within 2 years before filing this case.


12/1/17-Current26b.1




None

Name and address If any books of account and records are unavailable, explain why

26c. List all firms or individuals who were in possession of the debtor’s books of account and records when this case is filed.


12/1/17-Current26c.1

None

Name and address

26d. List all financial institutions, creditors, and other parties, including mercantile and trade agencies, to whom the debtor issued a financial statement within 2 years before filing this case.

Cascade Capital Group 3450 Oakton St. Skokie, IL 60076

26d.1

Midcap Financial Services, LLC - 551 5th Ave Suite 616 New York, NY 10176

26d.2

Formation Capital 3500 Lenox Rd Suite 510 Atlanta, GA 30326

26d.3

Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, MD 21244

26d.4

Have any inventories of the debtor’s property been taken within 2 years before filing this case?

27. Inventories

No

Yes. Give the details about the two most recent inventories

The dollar amount and basis (cost, market, or other basis)

of each inventory

Date of inventoryName of the person who supervised the taking of the inventory

Name and address of the person who has possession of inventory records




Name Address Position and nature of any interest

% of interest, if any

28. List the debtor’s officers, directors, managing members, general partners, members in control, controlling shareholders, or other people in control of the debtor at the time of the filing of this case.

PNW Healthcare Holdings, LLC

3220 Rosedale St. NW, Suite 200, Gig Harbor, WA 98335

Equity Holder 100%28.1

Dov E. Jacobs 3220 Rosedale St. NW, Suite 200, Gig Harbor, WA 98335

Manager28.2

Name Address Position and nature of any interest

Period during which position or interest was held

29. Within 1 year before the filing of this case, did the debtor have officers, directors, managing members, general partners, members in control of the debtor, or shareholders in control of the debtor who no longer hold these positions?

No

Yes. Identify below.

Within 1 year before filing this case, did the debtor provide an insider with value in any form, including salary, other compensation, draws, bonuses, loans, credits on loans, stock redemptions, and options exercised?

30. Payments, distributions, or withdrawals credited or given to insiders

No


Reason for providing this value

DatesName and address of recipient Amount of money or description and value of property

See Exhibit30.1

Relationship to debtor

Name of the parent corporation Employer identification number of the parent corporation

31. Within 6 years before filing this case, has the debtor been a member of any consolidated group for tax purposes?

No


PNW Healthcare Holdings, LLC 81-216980131.1

Name of the pension fund Employer identification number of the pension fund

32. Within 6 years before filing this case, has the debtor as an employer been responsible for contributing to a pension fund?

No





Part 14: Signature and Declaration

WARNING Bankruptcy fraud is a serious crime. Making a false statement, concealing property, or obtaining money or property by fraud inconnection with a bankruptcy case can result in fines up to $500,000 or imprisonment for up to 20 years or both.18 U.S.C. §§ 152, 1341, 1519, and 3571.

I have examined the information in this Statement of Financial Affairs and any attachments and have a reasonable belief that the information is true and correct.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on.

Signature of individual signing on behalf of the debtor

Position or relationship to the debtor

Printed name

Are additional pages to Statement of Financial Affairs for Non-Individuals Filing for Bankruptcy (Official Form 207) attached?

Dov E. Jacobs

1/7/2020

Manager

MM / DD / YYYY

No

Yes

/s/ Dov E. Jacobs



STATEMENT OF FINANCIAL AFFAIRS

EXHIBIT PART 2, QUESTION 3

CERTAIN PAYMENTS OR TRANSFERS TO CREDITORS

WITHIN 90 DAYS BEFORE FILING THIS CASE



Case #: 19-43788

SOFA 3 : Certain payments or transfers to creditors within 90 days before filing this case.

Creditor's Name Creditor’s Address Dates Total Amount

or value

Reasons for Payment

or Transfer

Aldercrest 21400 72nd Ave W, Edmonds, WA 98026 10/15/2019 $ 40,000.00 Other: Interfacility Loan

Aldercrest Total $ 40,000.00

Apex Global Solutions, LLC 400 Rella Blvrd Ste 200 Montebello NY 10901 9/11/2019 $ 16,201.56 Suppliers/Vendors/Services



Apex Global Solutions, LLC Total $ 49,240.93

Canyon NH LLc 10/24/2019 $ 30,000.00 Suppliers/Vendors/Services

Canyon NH LLc Total $ 30,000.00

Centers for Medicare And Medicaid Service Mail Stop CS-11-03 PO Box 7520 Baltimore MD 21207 9/10/2019 $ 3,466.27 Suppliers/Vendors/Services



Centers for Medicare And Medicaid Service Total $ 10,398.81

City of Bremerton (5101) 345 6th St Ste 100 Bremerton WA 98337 8/28/2019 $ 8,051.61 Suppliers/Vendors/Services

City of Bremerton (5101) 345 6th St Ste 100 Bremerton WA 98337 11/4/2019 $ 7,639.56 Suppliers/Vendors/Services

City of Bremerton (5101) Total $ 15,691.17

Cornerstone Healthcare Services 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 8/30/2019 $ 15,000.00 Suppliers/Vendors/Services











Cornerstone Healthcare Services Total $ 110,470.00

Cornerstone Self Insured 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 9/13/2019 $ 10,000.00 Suppliers/Vendors/Services





Cornerstone Self Insured Total $ 37,900.00

CRN Pool LLC 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 8/30/2019 $ 15,000.00 Suppliers/Vendors/Services




CRN Pool LLC Total $ 131,000.00

Department of Labor & Industries( Washington State) PO box 34974 Seattle WA 98124-1974 8/26/2019 $ 22,000.00 Suppliers/Vendors/Services

Department of Labor & Industries( Washington State) PO box 34974 Seattle WA 98124-1974 8/29/2019 $ 235.00 Suppliers/Vendors/Services

Department of Labor & Industries( Washington State) PO box 34974 Seattle WA 98124-1974 10/1/2019 $ 177.50 Suppliers/Vendors/Services

Department of Labor & Industries( Washington State) Total $ 22,412.50

Department of Revenue Washington State PO Box 47464 Olympia WA 98504-7464 8/26/2019 $ 12,376.56 Suppliers/Vendors/Services



Department of Revenue Washington State Total $ 36,848.41

Donald Sharman, MD 2601 Cherry Ave, STE 213 Bremerton WA 98310 10/23/2019 $ 5,500.00 Suppliers/Vendors/Services

Donald Sharman, MD 2601 Cherry Ave, STE 213 Bremerton WA 98310 11/18/2019 $ 5,500.00 Suppliers/Vendors/Services

Donald Sharman, MD Total $ 11,000.00

Foley Larder LLP IOLTA Trust Account 600 17th Street Ste 2020S Denver, CO 80202 11/21/2019 $ 16,666.67 Suppliers/Vendors/Services

Foley Larder LLP IOLTA Trust Account Total $ 16,666.67

HD Supply DSSI PO Box 509058 San Diego CA 92150-9058 9/16/2019 $ 1,544.77 Suppliers/Vendors/Services



HD Supply DSSI Total $ 7,842.48

Healthcare Services Group Inc 3220 Tillman Dr Ste 300 Bensalem PA 19020 8/30/2019 $ 13,210.90 Vendors/Services/Unsecured Loan









Healthcare Services Group Inc Total $ 172,255.74

Hocs Consulting 3009 Avenue K Brooklyn NY 11210 8/28/2019 $ 7,855.92 Suppliers/Vendors/Services

Hocs Consulting 3009 Avenue K Brooklyn NY 11210 9/18/2019 $ 675.00 Suppliers/Vendors/Services

Hocs Consulting Total $ 8,530.92

Interactive Medical Systems, Inc PO Box 843789 Los Angeles CA 90084-3789 8/29/2019 $ 3,051.77 Suppliers/Vendors/Services




Interactive Medical Systems, Inc Total $ 10,925.85

IPFS Corporation (Charlotte) PO Box 32144 New York NY 10087-2144 10/17/2019 $ 4,384.60 Suppliers/Vendors/Services

IPFS Corporation (Charlotte) PO Box 32144 New York NY 10087-2144 10/28/2019 $ 4,384.60 Suppliers/Vendors/Services

IPFS Corporation (Charlotte) Total $ 8,769.20

Midcap Financial Services, LLC 7255 Woodmont Ave Bethesda, MD 20814 8/26/2019 $ 14,196.94 Secured Debt









Midcap Financial Services, LLC 7255 Woodmont Ave Bethesda, MD 20814 9/3/2019 $ 37.14 Secured Debt















PNW - SOFA 3 - Dave V4 - Bremerton Health, LLC/SOFA 3

Page 1 of 3

Exhibit "SOFA 3" 1/5/2020



or value

Reasons for Payment

or Transfer




























































Midcap Financial Services, LLC Total $ 2,804,026.47

Omnicare, Inc DEPT. 781668 P O Box 78000 Detroit MI 48278 8/29/2019 $ 9,363.33 Suppliers/Vendors/Services



Omnicare, Inc Total $ 34,234.35

Philadelphia Insurance Companies One Bala Plaza Ste 100 Bala Cynwyd PA 19004 10/3/2019 $ 2,707.21 Suppliers/Vendors/Services



Philadelphia Insurance Companies Total $ 8,741.53

Phyt Rehab of Washington, Inc 171 Kings Highway Brooklyn NY 11223 8/29/2019 $ 13,000.00 Suppliers/Vendors/Services







Phyt Rehab of Washington, Inc Total $ 129,357.20

PointClickCare (Wescom Solutions) P.O. Box 674802 Detroit MI 48267-4802 8/26/2019 $ 3,708.25 Suppliers/Vendors/Services



PointClickCare (Wescom Solutions) Total $ 8,129.40

Puget Sound Energy (0513) 821 PO BOX 91269 Bellevue WA 98009-9269 8/28/2019 $ 2,968.69 Suppliers/Vendors/Services




Puget Sound Energy (0513) Total $ 12,165.16

Schryver Medical Sales and Marketing, LLC 12075 E 45th Ave Ste 600 Denver CO 80239 9/16/2019 $ 3,401.50 Suppliers/Vendors/Services

Schryver Medical Sales and Marketing, LLC 12075 E 45th Ave Ste 600 Denver CO 80239 10/28/2019 $ 4,336.16 Suppliers/Vendors/Services

Schryver Medical Sales and Marketing, LLC Total $ 7,737.66

Shomer Insurance Agency, Inc 4221 Wilshire Blvd. #222 Los Angeles CA 90010 11/21/2019 $ 11,248.30 Suppliers/Vendors/Services

Shomer Insurance Agency, Inc Total $ 11,248.30

SNF Payroll, LLC 17327 Ventura Blvd. Ste 330 Encino CA 91316 8/28/2019 $ 139,977.66 Vendors/Services







SNF Payroll, LLC Total $ 1,069,977.66

State of Washington P.O. Box 9501 Olympia Washington 98507-9501 8/28/2019 $ 64,998.00 Suppliers/Vendors/Services

State of Washington Total $ 64,998.00

Sysco Seattle P.O. BOX 97054 Kent WA 98064-9754 11/12/2019 $ 12,500.00 Suppliers/Vendors/Services

Sysco Seattle Total $ 12,500.00

Twin Med PO Box 847340 Los Angeles CA 90084-7340 8/26/2019 $ 13,599.71 Suppliers/Vendors/Services




Page 2 of 3




or value

Reasons for Payment

or Transfer


Twin Med Total $ 38,596.06

Washington State Dept of Labor & Industries PO Box 24106 Seattle WA 98124 11/4/2019 $ 10,000.00 Suppliers/Vendors/Services

Washington State Dept of Labor & Industries Total $ 10,000.00

Waste Management (3008) PO Box 13648 Philadelphia PA 19101 9/5/2019 $ 5,415.97 Suppliers/Vendors/Services

Waste Management (3008) PO Box 13648 Philadelphia PA 19101 10/28/2019 $ 2,694.72 Suppliers/Vendors/Services

Waste Management (3008) Total $ 8,110.69

Grand Total $ 4,939,775.16


Page 3 of 3




EXHIBIT PART 2, QUESTION 4

PAYMENTS OR OTHER TRANSFERS OF PROPERTY MADE

WITHIN 1 YEAR BEFORE FILING THIS CASE THAT BENEFITTED ANY INSIDER



Case #: 19-43788

SOFA 4. Payments or other transfers of property made within 1 year before filing this case that benefited any insider.

Insider’s Name Insider’s Address Dates Total Amount

or Value

Reasons for Payment or Transfer Relationship to Debtor

Cornerstone Healthcare Services 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 11/23/2018 $ 26,000.00 Management Fee/Expense Reimbursement Management Company






Cornerstone Healthcare Services 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 3/29/2019 $ 589.90 Management Fee/Expense Reimbursement Management Company

















Cornerstone Healthcare Services Total $ 377,039.90

Cornerstone Self Insured 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 11/23/2018 $ 15,000.00 Pass through expense - insurance Management Company


















Cornerstone Self Insured Total $ 314,932.64

CRN Pool LLC 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 11/23/2018 $ 15,500.00 Staffing Staffing Company





PNW - SOFA 4 - Dave V4 - Bremerton Health, LLC/4

Page 1 of 2

Exhibit "4" 1/5/2020


Insider’s Name Insider’s Address Dates Total Amount

or Value

Reasons for Payment or Transfer Relationship to Debtor



CRN Pool LLC Total $ 142,500.00

Grand Total $ 834,472.54

PNW - SOFA 4 - Dave V4 - Bremerton Health, LLC/4

Page 2 of 2

Exhibit "4" 1/5/2020



EXHIBIT

PART 13, QUESTION 30

PAYMENTS, DISTRIBUTIONS, OR WITHDRAWALS

CREDITED OR GIVEN TO INSIDERS



Case #: 19-43788

SOFA 30 : Payments, distributions, or withdrawals credited or given to insiders

Creditor's Name & Address Amount of money Dates Reason for providing the value Relationship to Debtor

Cornerstone Healthcare Services 3220 Rosedale St. NW Ste. 200 Gig Harbor,

WA 98335 $26,000.00 11/23/2018

Management Fee/Expense

Reimbursement Management Company


WA 98335 $20,000.00 11/29/2018




WA 98335 $16,450.00 2/1/2019




WA 98335 $3,000.00 2/4/2019




WA 98335 $16,000.00 3/22/2019




WA 98335 $22,000.00 3/27/2019




WA 98335 $6,000.00 3/29/2019




WA 98335 $589.90 3/29/2019




WA 98335 $5,000.00 4/5/2019




WA 98335 $40,000.00 4/12/2019




WA 98335 $65,000.00 4/19/2019




WA 98335 $20,000.00 5/10/2019




WA 98335 $5,000.00 5/22/2019




WA 98335 $12,000.00 5/24/2019




WA 98335 $15,000.00 6/7/2019




WA 98335 $20,000.00 6/21/2019




WA 98335 $10,000.00 7/5/2019




WA 98335 $4,000.00 7/9/2019




WA 98335 $7,000.00 7/10/2019




WA 98335 $10,000.00 7/24/2019




WA 98335 $4,000.00 8/9/2019




WA 98335 $25,000.00 8/16/2019




WA 98335 $25,000.00 8/21/2019



Cornerstone Self Insured 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA

98335 $15,000.00 11/23/2018 Pass through expense - insurance Management Company



































CRN Pool LLC 3220 Rosedale St. NW Ste. 200 Gig Harbor, WA 98335 $15,500.00 11/23/2018 Staffing Staffing Company







Grand Total $834,472.54

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official form 207 · in re bremerton health, llc case no. 19-43788 none list the legal actions,...

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